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A Patient-Centered Fall Prevention Toolkit


The Agency for Healthcare Research and Quality (AHRQ) is the lead federal agency, working within the U.S. Department of Health and Human Services, that is charged with improving the quality and safety of America’s health-care system. Committed to translating research and evidence into practice, AHRQ convenes expert panels to develop training resources, tool and toolkits, and resources made publicly available to organizations to implement. The AHRQ “mission is to produce evidence to make healthcare safer, higher quality, more accessible, equitable, and affordable” (AHRQ, www.ahrq.org).

A research and clinical team under the leadership of Dr. Patti Dykes (PhD, MA, RN, FAAN, FACMI), Program Director for Research in the Center for Patient Safety Research and Practice at Brigham and Women’s Hospital, began to investigate fall prevention in 2007, learning then that evidence was insufficient to link fall risks to interventions to mitigate and eliminate these risks. They received funding from the Robert Wood Johnson Foundation to examine the primary causes of patient falls in hospitals and the most feasible interventions, when implemented, would prevent falls.

They learned that universal fall risk signage was ineffective, communication within and among clinical care teams about fall prevention was inconsistent, and everyone on the care team, including patients and family, must work together (https://www.falltips.org/about-fall-tips/). This foundational study provided the foundational purpose for a prolific research and evidence-based practice portfolio led by Dr. Dykes and joined by co-investigating health care teams to develop, test, implement and further evaluate Falls: TIPS (Tailoring Interventions for Patient Safety), a fall prevention toolkit that consists of a formal risk assessment based on the Morse Fall Scale and tailored care plan for each patient. Core to this program is patient and family engagement, active partners in customized fall prevention for each patient.

Because of the published success of the Falls TIPS program to reduce hospital falls by 25% and use in more than 100 hospitals in the US and internationally, AHRQ received a funded research grant to help patients and family members work with nurses and other healthcare provided to reduce falls in hospitals. Through this grant, the partnership of Dr. Dykes’ and Dr. Bates’ team and others, the AHRQ’s Patient Safety Learning Laboratory produced this evidence-based toolkit for hospitals. AHRQ has made available to all organizations the Fall TIPS: A Patient-Centered Fall Prevention Toolkit and part of its hospital patient safety toolkit portfolio. This site here will take you directly to the AHRQ website. And on the AHRQ website, you are taken directly to the Falls TIPS Toolkit website: https://www.falltips.org/ On this site, you will access information about Falls TIPS, the 5 steps to implement Falls TIPS, and success stories.

The five steps to implementation will hopefully sound familiar to you:

  1. Secure leadership buy-in
  2. Secure Nurses’ buy-in
  3. Train champions
  4. Plan implementation
  5. Communicate consistently.

Guidance and resources are provided for each step to help your organization.

The success stories showcase Montefiore Medical Center in NY City, New York Presbyterian, and St. Joseph’s Health in Paterson, NJ. You will also read a glimpse of what patients and family are saying about Fall TIPS.

You will also access resources:

  • Fall TIPS Champion Training Slides
  • Evaluation of Patient-Centered Fall-Prevention Toolkit to Reduce Falls and Injuries Slides
  • Fall Prevention Knowledge Test with answer key and instructions to analyze data for this test
  • Fall TIPS instruction sheets for nurses, nursing assistance, and patients
  • Falls TIPS Quality Audit and Audit Instructions & Reliability Guide
  • Peer Feedback Exercises

Plus more…

In additional to these resources, you will also find three videos, of which one is a super-user training video. Check these out!

The third resource group provided to you at your fingertips is publications. When you click on the publication link, you will find over 25 peer-reviewed fall-related publications, a progressive publication portfolio, 2009-2021. I suggest scanning these articles and begin your selection for journal club articles to discuss with your Fall and Injury Prevention Committee.

I hope that you will visit the Falls TIPS Toolkit website as an organization, Falls Prevention Committee, and/or Clinical Practice Committee.

Your organization may also join the Falls TIPS Collaborative. This Collaborative was formed by Brigham and Women’s Hospital in Boston, Montefiore Medical Center, and New York-Presbyterian in New York. The purpose of this collaborative is to spread the Fall TIPS Toolkit to ensure that all patients have access to evidence-based fall and prevention care.

There is no cost to using the Falls TIPS Program or joining the Falls TIPS Collaborative. Dr. Dykes and her team has always asked that hospitals let them know about choosing to use this program to not modify any program materials.

George Reamsnyder, Curbell Medical’s Fall Program Management Specialist, and I also invite you to meet Dr. Dykes, our guest at Care Team Conversations. Learn directly from her about her nursing career journey that led her interest into fall prevention, and her guidance to reduce barriers and facilitators to program implementation. You will also learn about her diverse range of research interests as she shares about a couple of studies that enlighten our audience about the important possibilities of machine learning from electronic medical records. You can listen to her podcast at Curbell Medical’s Fall Management Education here — scroll down to Podcasts.

Thank you for reading my message. I welcome your comments. I would love to hear back from you.


All my best, Pat


Pat Quigley



Agency for Healthcare Research and Quality: Home. Available: here Accessed July 10, 2022

Falls TIPS: A Patient-Centered Fall Prevention Toolkit. Content last reviewed February 2021. Agency for Healthcare Research and Quality, Rockville, MD. Available: https://www.ahrq.gov/patient-safety/settings/hospital/fall-tips/index.html




Dr. Patricia Quigley is a Nurse Consultant, Nurse Scientist, Former Associate Director and VISN 8 Patient Safety Center of Inquiry. She is both a Clinical Nurse Specialist and a Nurse Practitioner in Rehabilitation, and her contributions to patient safety, nursing and rehabilitation are evident at a national level, with emphasis on clinical practice innovations designed to promote elders’ independence and safety. She is nationally known for her program of research in patient safety, particularly in fall prevention. The falls program research agenda continues to drive research efforts across health services and rehabilitation researchers.